|Year : 2019 | Volume
| Issue : 1 | Page : 19-23
King Saud Medical City Intensive Care Unit: A critical and cost-focused appraisal
Abdulrahman Alharthy, Dimitrios Karakitsos
Department of ICU, King Saud Medical City, Riyadh, KSA
|Date of Web Publication||30-May-2019|
Department of Critical Care, King Saud Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
Intensive care unit (ICU) cost analysis has not been extensively addressed in the Kingdom of Saudi Arabia. We have implemented cost analysis (2015–2016) at the largest polyvalent ICU of the Kingdom (King Saud Medical City). Our block model analysis assimilated both modified Therapeutic Intervention Scoring System (TISS) and Omega scoring points to evaluate the overall cost; while, specific utilization elements were included in such as medication, procedural, laboratory, radiology, physiotherapy, nursing/physician, and overhead/other costs. The overall cost (Saudi Riyals [SAR]/ICU patient/day) averaged for TISS/Omega scores and adjusted for 2015–2016 inflation rates was approximately 23.269 (TISS: 167 points; Omega: 173 points generating predictive costs scores which were approximating the aforementioned score [R2 validated 0.91 and 0.90, respectively, all P < 0.005). Thereafter, we have applied effective antibiotic stewardship program and control of procedural supplies, novel administration policies, diversification of the ergonomy and clinical orientation, early mobilization of patients, increase of by-the-bed critical care ultrasound applications and decrease in the length of stay. The cost was reduced to 19.800 SAR (15%) in 2017–2018 that is comparable to international standards. Preliminary follow-up cost analysis (2019) is confirming projections of stabilizing the ICU cost <18.000 SAR (4790 USD)/patient/day. Our budget-cut policy has provided the department with a vital investment space to integrate new therapeutic technologies.
Keywords: Budget-cut policies in health care, cost analysis scoring systems, intensive care unit
|How to cite this article:|
Alharthy A, Karakitsos D. King Saud Medical City Intensive Care Unit: A critical and cost-focused appraisal. Saudi Crit Care J 2019;3:19-23
|How to cite this URL:|
Alharthy A, Karakitsos D. King Saud Medical City Intensive Care Unit: A critical and cost-focused appraisal. Saudi Crit Care J [serial online] 2019 [cited 2020 Jun 6];3:19-23. Available from: http://www.sccj-sa.org/text.asp?2019/3/1/19/259473
| Introduction|| |
The Kingdom of Saudi Arabia (KSA) is one of the largest Middle Eastern countries covering an area of 2.5 million km2. With an estimated population of approximately 30 million residents and an annual growth rate of 2.7%, the Saudi Arabian public and private health-care sectors are rapidly expanding to accommodate an increasing demand on health-care services. The Saudi Ministry of Health (MOH) has a crucial role to play in boosting further public and private health organizational development in the years to come. According to the World Health Organization, the Saudi health-care system is ranked 26th among 190 of the world's health-care systems. In the year 2012, the cumulative budget allocation for the MOH was doubled to 54 billion (6.6% from the total government budget) Saudi Riyals (SAR) compared to around 25 billion (5.6%) SAR in the year 2008. Notably, the MOH's strategy was underlined by the expansion of critical care services to enhance the accessibility and feasibility of such services.
However, the absence of good databases, low research activity, and budget cuts rendered the expansion of MOH affiliated critical care services rather problematic. Surely, the lack of research funds is a global reality as in the example, in the United States, the research funding for critical care ranges from 1.7% to 6.3% of the federal research budget. On the other hand, it is of note that KSA's responsibility for the Hajj has affected immensely the Kingdom's advanced healthcare infrastructure as reflected the deployment of more than 130 centers equipped with the latest emergency management medical systems. Each year, the MOH further boosts the development of new state of the art critical care services devoted for the accommodation of Hajj pilgrims However, equal focus should be given to its largest hospital (King Saud Medical City [KSMC] in Riyadh), with its intensive care unit (ICU) being one of the busiest and outsized ICU departments in the world [Figure 1].
|Figure 1: Riyadh structural intensive care unit configuration (Data derived from Ministry of Health 2013 year statistics)|
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The polyvalent ICU of KSMC remains a dynamic, multipurpose training center providing high-quality care to the citizens of the Kingdom. Under the vision of its leader, Dr. Abdulrahman Alharthy, the ICU is progressing rapidly toward a diverse, modern department providing quality critical care services. Since 2015, the outsized ICU department has been further reorganized into various subunits such as medical, respiratory, burn, surgical and postoperative, trauma, isolation wings and recently neurocritical care and extracorporeal membrane oxygenation program to address in a more efficient manner the complex features of critical care patients. The well-structured Saudi Fellowship and Residency programs in Critical Care which run within the premises of the department, along with oriented by-the-bed training, focused academic, and research activities and exposure to diverse educational resources designated for both physicians and nursing staff, which are led by a multidisciplinary team of ICU Consultants, clinical educators, and invited lecturers, remain distinct features of the high academic quality of the department. The high training quality is a pivotal tool in the arsenal of the ICU department, which is designated to counteract an excessive clinical workload each year, to achieve a better standard of care. The aforementioned workload is reflected in the baseline features of ICU patients presented in [Table 1].
|Table 1: Baseline features of intensive care unit patients (years 2015-2016; data derived from King Saud Medical City records; courtesy of Ms. Reem Mohammed)|
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The vast majority of patients were admitted to the Trauma and Neurocritical ICU, while a significant number of patients were also admitted to other pertinent subspecialty ICU units. KSMC-ICU accommodates an almost equal number of KSA versus non-KSA nationals to provide high-quality care to all citizens of the Kingdom; while the estimated mortality rate adjusted for APACHE IV score on the admission of KSMC-ICU hospitalized patients remains comparable to global health quality and Hajj standards. For example, in a prospective cohort study of the critically ill patients in 2009, 110 patients needed ICU admission due to various reasons. They had a mean APACHE IV of 60.5. Sixty (54.6%) patients required ventilation on admission. Their median predicted mortality by APACHE IV was 14%. However, with the ability to provide a state of the art full-service intensive care, their adjusted mortality rate was only 6.4%. Although the figures are not comparable, taking into account the higher APACHE IV scoring and predicted mortality rate observed in KSMC-ICU patients, the overall adjusted mortality rate (i.e., 6.9% in 2016) cannot be underestimated.
The main admission sources of the ICU are outlined in [Table 2] depicting an increased referral rate from other hospitals for the year 2016.
|Table 2: Main intensive care unit admission sources (years 2015-2016; data derived from King Saud Medical City records)|
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The most common ICU admission diagnoses are briefly presented in [Table 3].
|Table 3: Intensive care unit admission statistics (years 2015.2016; data derived from King Saud Medical City records)|
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| Intensive Care Unit Cost Analysis|| |
The analysis of ICU cost data has been traditionally beset by a number of distinctive problems: methodological study differences; differing methods of costing, patient-specific and nonspecific, “top-down” and “bottom-up” costing; the ambiguous relation between costs and proxy variables, such as activity indices (Therapeutic Intervention Scoring System [TISS], the Omega score) and hospital length of stay; as well as particular modeling difficulties, the distinct skewed distribution of the cost variable, the lack of a standard variable set compared with mortality algorithms, and the variably low multivariable predictive power of the developed models.,,,,,,,,,,
However, models that calculate the cost based on reproducible cost components and block analysis have largely facilitated the analysis of ICU cost dependent surely on the viewpoint of the analysis. For example, health-care costs in the US exceeded a total over $2 Trillion per year during the last 20 years or so, which is over 15% of the US Gross Domestic Product and registering a 210% increase in ICU costs from 1995 to 2015. The latter could be partially justified by the fact that a growing percentage of hospitalized patients have been receiving critical care with a day in the ICU costing approximately $4500–$6800. In the US, ICUs account for 10% of all inpatient beds and 1 out of every 3 dollars spent in the hospital, while $1 billion was spent on sedation alone at the end of the 1990s. Increases are in part due to an aging population: Sepsis is predicted to rise by 30%; while changes in cost are targeted toward disease-specific management, organization, and prevention.,,
In that sense, ICU cost data analysis has not been adequately addressed in the KSA. Hence, we have conducted a preliminary ICU cost analysis using cost component and block analysis at KSMC-ICU. The latter was based on the KSMC-ICU patient stay, including all related management activity, but excluding costs associated with the provision of services external to the ICU, and was generated by data derived from our last 2 years' (2015–2016) records.
We utilized modified TISS and Omega scoring while our block analysis included in specific utilization elements such as: (1) drugs: data on actual drug usage, including parenterally administered fluids were collected daily; (2) procedural: medical and surgical supplies, all medical and surgical supplies were identified and recorded, by procedure or by individual item as per hospital records; (3) pathology costs: all pathology tests consumed were recorded by individual patient as per hospital records; (4) radiology costs: these were recorded by individual patient (i.e., chest and other X-rays, computed tomography, magnetic resonance imaging scans, and invasive angiography) and costed using procedure costs as per hospital records; (5) physiotherapy costs: each physiotherapy intervention was recorded by individual patient and costed using a standard unit of time; (6) nursing staff costs: nursing salary and wage costs were approximated using actual minutes of nursing time for each ICU patient day (time spent on educational activities was excluded), standard nursing practice was 1–1 nurse patient ratio; (7) medical staff costs: medical salary costs were approximately allocated to patients on the basis of days of ICU stay (time spent on educational activities was excluded), all medical staff were “full-time.” (8) overhead costs: overhead costs attributable to ICU operation were derived using the Yale DRG costing methodology, and allocated to patients on the basis of ICU length of stay; and (9) other costs: these were the residual costs reported that remained unallocated to patients (such as administration, repairs and maintenance, orderlies salaries and wages, linen and domestic supplies) and were approximately allocated to patients on the basis of ICU length of stay.
Examples of baseline features of the study population that were used as cofactors in block analysis and thus integrated as average values for the years 2015–2016 included in: length of stay (11 days), duration of mechanical ventilation (14 days), number of total tracheostomies performed (313), rate of central venous and arterial lines inserted (60%; 50%, respectively), rate of continuous renal replacement treatment used (61%), rate of cardiopulmonary resuscitation sessions attempted in the ICU (14%), rate of chest X-ray (92%), computed tomography scans (80%), magnetic resonance imaging scans (65%), invasive angiographies (38%), echocardiographic (68%) and generic ultrasound (55%) examinations performed, and rate of general laboratory (95%) and pathology (42%) examinations performed among others. Thereafter, a block-specific analysis based on the integrated element analysis was attempted by collecting daily data in a retrospective manner. The assimilation, of the calculated TISS and Omega points, was attempted to further evaluate various demographic details and ICU stay variables as well as to facilitate the generation of an overall estimation. The aforementioned scores were integrated into the final model as independent predictors. Finally, model performance was assessed by R2 and for the validation set; the R2 was computed as the square of the correlation of cost and the predicted (cost) variable. Nine extreme patient outliers were excluded from the final analysis. Further subgroup analysis (i.e., survivors versus nonsurvivors) was not attempted as this was not the end-point of the current analysis.
An example of element specific analysis (drugs) is presented in [Table 4] for the most commonly prescribed drug categories in the ICU (SAR price adjusted for inflation 2015).
|Table 4: Courtesy of Dr. Basheer; King Saud Medical City - intensive care unit clinical pharmacist|
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The overall ICU medication cost per year ranged approximately at 1.6–2 billion SAR whereas the adjusted cost range per ICU patient per day was approximated at 5.500–7.000 SAR (SAR/ICU patient/day).
Another example of element-specific analysis (procedural) for commonly used medical supplies in the ICU is presented in [Table 5].
|Table 5: Courtesy of Mr. Mohammed Attollah Al Shammari and Mr. Muhhannad Ibrahim Al Hamdan|
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The baseline raw cost of an ICU bed starts at 2000 SAR (for adult/pediatric and neonatal cases on admission) and can escalate thereafter according to all factors mentioned in the aforementioned paragraphs. Our block model analysis was performed following the element specific analysis accordingly. The block analysis assimilated both modified TISS/Omega points for assessing the overall cost which is presented in [Table 6].
|Table 6: Block model analysis for intensive care unit daily cost (average cost per intensive care unit patient per day)|
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The predictive values of both Omega and TISS scores were comparable to previously published models in the literature.,, The overall ICU cost/patient/day at KSMC-ICU as estimated in this study (23.269 SAR) reflects largely to the current US ICU cost trends as previously described. However, this average value, although falling in the North American standard cost range, is in fact somewhat higher compared to the current North American average value trending at 4.900 USD.
Cost trends and future perspectives
Taking into account that the implementation of novel and indeed costly therapies is paramount for the development of critical care services in the Kingdom the projected ICU cost could further increase in the upcoming years. However, here lies a dilemma: shall we avoid implementing new technologies and novel therapies in the ICU environment or follow a strict budget-cut policy? In that sense, the introduction of simple and even occasionally clinically necessary bundle of countermeasures to reduce the daily ICU cost could be in line with a budget-cut policy but at the same time could be preparing the ground for a strategic point of care investments. Notably, KSMC-ICU has succeeded in reducing the cost, under the leadership of its chairman based on preliminary follow-up analysis (2018-2-19) by applying simple strategic countermeasures. The application of a strict antibiotic stewardship program, better control of procedural supplies, strict administration policies to minimize overheads along with the implementation of new clinical policies such as the reduction of prescribed sedatives, diversification of the department in terms of ergonomy and clinical orientation, early mobilization of ICU patients (mobilization project), increase of dedicated by-the-bed critical care ultrasound applications, and decrease in the length of ICU stay represent a simple bundle of countermeasures which reduced dramatically the raw ICU cost/patient/day from 23.100 to 19.800 SAR (approximately 15%) in 2018; while improving the standard of care. A preliminary follow-up cost analysis in 2019 is confirming projections of stabilizing the ICU cost <18.000 SAR or 4790 USD/patient/day. This budget-cut policy could provide the department with the necessary vital investment space to integrate novel therapeutic technologies that will improve the standard of care and upgrade the critical care service provided to the citizens of the Kingdom. In conclusion, the actual ICU cost/patient/day in our institution is comparable to international standards and can be further optimized by the application of budget-cut policies that do not harm but rather improve the standard of critical care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]